Prevalence, incidence and associated factors of pressure ulcers in home palliative care patients: A retrospective chart review

Body mass index and pressure injuries risk in hospitalized adult patients: A dose-response analysis

BACKGROUND

The association between underweight and pressure injuries (PIs) has been established in several studies. However, there is a lack of well-designed research investigating the connection between overweight and obesity with these injuries.

OBJECTIVE

This meta-analysis aims to investigate the dose-response relationship between body mass index (BMI) and the risk of PIs in adult hospitalized patients.

METHODS

PubMed, Web of Science, and MEDLINE Databases were searched from inception to May 2024. Observational articles with at least three BMI categories were included in the study. BMI was defined as underweight, normal weight, overweight, and morbid obesity for the meta-analysis. The non-linear relationship between BMI and the risk of PIs in hospitalized adults was investigated using restricted cubic spline models. Fractional polynomial modeling was used.

RESULTS

Eleven articles reporting at least 3 categories of BMI met the inclusion criteria, including 31,389 participants. Compared to patients with normal weight, those with underweight, obesity, and morbid obesity exhibited an increased risk of PIs, with odds ratios of 1.70 (95%CI:1.50-1.91), 1.12 (95%CI:1.02-1.24), 1.70 (95%CI:1.13-2.55), respectively. A J-shaped dose-response model was established for the relationship between PI risk and BMI (Pnon-linearity < 0.001, Plinearity = 0.745).

CONCLUSION

The J-shaped dose-response pattern revealed that underweight, obesity and morbid obesity heightened the risk of PIs in hospitalized adults. Lower and higher BMI values may signify an increased risk for PIs, particularly among the elderly with lower BMI, providing valuable guidance for medical staff.

Development and validation of a risk prediction model for community-acquired pressure injury in a cancer population: A case-control study

BACKGROUND

Patients with cancer are susceptible to pressure injuries, which accelerate deterioration and death. In patients with post-acute cancer, the risk of pressure injury is ignored in home or community settings.

OBJECTIVE

To develop and validate a community-acquired pressure injury risk prediction model for cancer patients.

METHODS

All research data were extracted from the hospital's electronic medical record system. The identification of optimal predictors is based on least absolute shrinkage and selection operator regression analysis combined with clinical judgment. The performance of the model was evaluated by drawing a receiver operating characteristic curve and calculating the area under the curve (AUC), calibration analysis and decision curve analysis. The model was used for internal and external validation, and was presented as a nomogram.

RESULTS

In total, 6257 participants were recruited for this study. Age, malnutrition, chronic respiratory failure, body mass index, and activities of daily living scores were identified as the final predictors. The AUC of the model in the training and validation set was 0.87 (95 % confidence interval [CI], 0.85-0.89), 0.88 (95 % CI, 0.85-0.91), respectively. The model demonstrated acceptable calibration and clinical benefits.

CONCLUSIONS

Comorbidities in patients with cancer are closely related to the etiology of pressure injury, and can be used to predict the risk of pressure injury.

IMPLICATIONS FOR PRACTICE

This study provides a tool to predict the risk of pressure injury for cancer patients. This suggests that improving the respiratory function and nutritional status of cancer patients may reduce the risk of community-acquired pressure injury.

Dose-response relationships between body-mass index and pressure injuries occurrence in hospitalized patients: A multi-center prospective study

BACKGROUND

Pressure injuries (PIs) are one of the leading potentially preventable hospital-acquired complications associated with prolonged hospital length, poor quality of life and financial burden. The relationship between body mass index (BMI) and PIs occurrence is controversial.

OBJECTIVE

The aim of this study was to further examine relationships between BMI and PIs occurrence in hospitalized patients.

DESIGN

A multi-center prospective study.

SETTING

39 hospitals located in northwest China from April 2021 to July 2023.

PARTICIPANTS

175,960 hospitalized patients aged over 18 years were enrolled, and 170,800 patients were included in the final analysis.

METHODS

BMI and clinical characteristics were assessed at baseline. PIs assessment were performed by trained nurses, with data recorded for the presence, the location and stage of each PI. For staging PIs, the National Pressure Ulcer Advisory Panel（NPUAP） staging system were used. The multivariate logistic regressions analysis and restricted cubic splines (RCS) models were used to explore associations between BMI and PIs, adjusting for potential confounders.

RESULTS

Of 175,960 participants, 5160 were excluded from analyses. The multivariate logistic regression model identified a positive relationship between under-weight BMI and risk of PIs occurrence (OR = 1.60, 95% CI:1.18-2.17). We also found U shaped association between BMI and PIs occurrence (non-linear P < 0.001). BMI less than 23 kg/m2 significantly increased risk of PIs, and there was a tendency to increase risk of PIs at BMI higher than 30 kg/m2. We stratified participants by sex to further investigate their association and found the risk of PIs increases substantially in women at BMI below 17 kg/m2 and in men at BMI below 23 kg/m2.

CONCLUSIONS

The present study indicated that there was an approximate U shaped relationship between BMI and PIs occurrence, and this association was potentially different between men and women.

Family-centred empowerment using telenursing on pressure injury incidence in post-discharge stroke patients

OBJECTIVE

The aim of this study was to evaluate the effect of a family-centred empowerment intervention on the incidence, stage and status of pressure injury (PI) in patients diagnosed with stroke during the post-discharge period with a telenursing approach.

METHOD

This randomised controlled clinical trial (RCT) was conducted with patients admitted to Ghaem Hospital in Mashhad and who were diagnosed with stroke. Patients were randomly assigned to one of two equal-sized groups: intervention and control. Family education and follow-up of the intervention group was performed using WhatsApp messenger for one month. Caregivers of patients in the control group received the routine training programme. The incidence, stage and status of PIs of both groups were measured at the beginning and at one month later using the Braden Scale, the EPUAP/NPUAP Classification System, and the Pressure Ulcer Scale for Healing (PUSH).

RESULTS

A total of 60 patients took part in the RCT (30 patients allocated to each group). The incidence of PI in the control group was significantly higher than in the intervention group (p<0.001). The results showed significantly lower stages of PI in the intervention group than in the control group (p<0.001 and p<0.05 for univariable and multivariable models, respectively). The results showed a significantly lower PUSH score in the intervention group than in the control group (p<0.001 and p<0.05 for univariable and multivariable models, respectively).

CONCLUSION

The findings of this RCT show that the empowerment and training of caregivers of patients diagnosed with stroke after discharge using telenursing can reduce the incidence and severity of PIs and improve their status in these patients.

Facilitators and barriers to pressure injury prevention, management and education: Perspectives from healthcare professionals-A qualitative study

This study aims to (1) characterize healthcare professionals' (HCPs') experiences related to the prevention and management of pressure injuries (PIs) and (2) explore the educational needs of individuals with a past or current history of PIs and their caregivers from the perspective of HCPs. This is a qualitative descriptive study. HCPs (n = 18) were interviewed using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim and coded using NVivo. Three overarching themes encompassing various dimensions were identified: (1) Facilitators related to PI prevention and management, (2) Challenges related to PI prevention and management and (3) Recommendations for improving patient and caregiver PI education. HCPs identified a greater number of challenges than facilitators related to PI care. This study emphasizes the importance of a patient-centred and interprofessional approach to patient education for PI prevention and management. Meaningful interventions focused on the patient may improve health literacy and empower patients and caregivers in PI care. Investing in preventive measures and raising awareness are crucial to reducing PI incidence. The findings have implications for HCPs and researchers seeking to enhance patient care and promote effective PI prevention strategies.

Effect evaluation of new dressing URGOTULRANGE in the treatment of pressure injury

BACKGROUND

Pressure injury (PI) is a local injury of the skin and/or soft tissue located at the bone caused by medical or other equipment and is common in long-term bedridden patients.

OBJECTIVE

To investigate the clinical effect of Urgotul foam dressing in the treatment of stage 3 ∼ 4 PI and deep tissue PI.

METHODS

A total of 38 patients with stage 3 ∼ 4 PI and deep tissue PI admitted to Jinan Central Hospital from January 2016 to December 2018 were selected and randomly divided into a control group (dressing change plus silver ion cream dressing) and an observation group (dressing change plus Urgotul Absorb non-border foam dressing), with 19 cases in each group. After 4 weeks of treatment, the pain intensity during dressing change and the treatment efficacy for PI wounds were compared between the two groups.

RESULTS

There were no differences in gender (P= 0.740), age (P= 0.130), single wound area (P= 0.673), consultation department (P= 0.972), stage (P= 0.740), presence of undermining (P= 0.721), deep tissue PI (P= 0.721), and systemic antibiotic therapy (P= 1.000) between the two groups, which were comparable. The treatment effect of the observation group was better than that of the control group (P= 0.003), and the pain score of the observation group was lower than that of the control group (P< 0.001).

CONCLUSION

Urgotul Absorb non-border foam dressing has a good effect in the treatment of stage 3 ∼ 4 PI and deep tissue PI and can relieve patients' pain, and is thus worth promoting.

Nursing Students' Knowledge on Pressure Injuries Following a Blended-Learning Unit: A Quasi-experimental Study

OBJECTIVE

To assess first-year bachelor's degree in nursing students' knowledge about pressure injury (PI) etiology, classification, prevention, and management following blended learning and clinical practice.

METHODS

A quasi-experimental design was used. Nursing students' PI knowledge was measured using the French version of the Pressure Ulcer Knowledge Assessment Tool (PUKAT) at three time points: baseline (before a blended-learning unit, consisting of 2 hours of e-learning and 3 hours of practical workshop), after the blended-learning unit, and after clinical practice.

RESULTS

A total of 21 students participated over the three time points. At baseline, the mean percentage of correct answers on the PUKAT was 45.8%. This score increased to 59.2% following the blended-learning unit and 65% after completing the clinical practice (F2,58 = 19.08; P = .00). Over the three time points, students scored highest on knowledge of risk assessment and lowest on knowledge of prevention.

CONCLUSIONS

Blended-learning units combining e-learning and practical workshops are valuable tools to increase students' knowledge about PIs. The PUKAT enables the evaluation of changes in students' knowledge following a teaching unit on PIs. However, more research is needed to assess the long-term evolution of knowledge and the impact of this teaching on clinical practice.

Characteristics and risk factors of facial pressure injuries in acute inpatients using noninvasive positive pressure ventilation: A retrospective case control study

OBJECTIVE

To explore the characteristics and risk factors of facial pressure injuries in patients using noninvasive positive pressure ventilation.

SETTING AND SAMPLE

Patients who developed facial pressure injuries due to non-invasive positive pressure ventilation at a teaching hospital in Taiwan from January 2016 to December 2021 were selected, resulting in a total of 108 patients in our case group. A control group was formed by matching each case by age and gender to three acute inpatients who had used non-invasive ventilation but had not developed facial pressure injuries, resulting in 324 patients in the control group.

RESEARCH METHODOLOGY

This study was a retrospective case-control study. The characteristics of the patients who developed pressure injuries at different stages in the case group were compared, and the risk factors of non-invasive ventilation-related facial pressure injuries were then determined.

RESULTS

Higher duration of non-invasive ventilation usage, higher length of hospital stay, lower Braden scale score, and lower albumin levels in the former group. The results of multivariate analysis from binary logistic regression involving the duration of non-invasive ventilation usage demonstrated that the patients who used this device for 4-9 days and 16 days were at greater risk of facial pressure injuries than those who used it for 3 days; in terms of the Braden scale score, higher Braden scale scores were correlated with a higher risk of facial pressure injuries. In addition, albumin levels lower than the normal range were correlated with a higher risk of facial pressure injuries.

CONCLUSION

Patients with pressure injuries at higher stages had a higher duration of non-invasive ventilation usage, higher length of hospital stay, lower Braden scale scores, and lower albumin levels. Thus, a longer duration of non-invasive ventilation use, lower Braden scale scores, and lower albumin levels were also risk factors for non-invasive ventilation-related facial pressure injuries.

IMPLICATIONS FOR CLINICAL PRACTICE

Our results serve as a useful reference for hospitals, both in creating training programs for their medical teams to prevent and treat facial pressure injuries and in drafting guidelines for assessing risk in order to prevent facial pressure injuries caused by non-invasive ventilation. The duration of device usage, Braden scale scores, and albumin levels in particular should be seriously monitored to reduce the occurrence of facial pressure injuries in acute inpatients treated with non-invasive ventilation.

Incidence and risk factors for pressure injury in hospitalized non-small cell lung cancer patients: A retrospective observational study

AIM

This study aimed to identify the incidence and risk factors for pressure injury in patients hospitalized for non-small cell lung cancer (NSCLC).

METHODS

This retrospective observational study was conducted in 645 adults who were hospitalized for NSCLC. Clinicopathological characteristics were compared between NSCLC patients with pressure injury and those without pressure injury.

RESULTS

Among total 645 patients, 180 patients showed pressure injury with an incidence of 27.9%. Patients with pressure injury showed increased serum C-reactive protein (CRP) levels (P < 0.001), increased neutrophil-lymphocyte ratio (P = 0.002), and increased platelet-lymphocyte ratio (P = 0.001) more often. Increase in serum CRP levels at the time of admission was the major risk factor for development of pressure injury in NSCLC patients (OR = 2.20; 95% CI [1.40-3.45]; P = 0.001). Also, among major inflammatory markers, serum CRP levels at the time of admission showed weak negative correlation with the period from admission to the development of pressure injury (r = -0.216, P = 0.004).

CONCLUSION

By checking serum CRP levels at the time of admission, the NSCLC patients at high risk for the development of pressure injury can be identified in advance and the occurrence of pressure injury can be reduced by applying more active preventive nursing care.

CLINICAL TRIAL REGISTRATION NUMBER

KCT0006570.

Spiritual well-being, symptoms and performance of patients under palliative care

OBJECTIVES

to assess the relationship between spiritual well-being, symptoms and performance of patients under palliative care.

METHODS

this is a descriptive correlational study, conducted with 135 patients seen in palliative care outpatient clinics. Karnofsky Performance Status Scale, Edmonton Symptom Assessment Scale, Spirituality Scale and Hospital Anxiety and Depression Scale were used. Data were submitted to descriptive statistical analysis and Spearman's correlation.

RESULTS

among participants, 68.2% were cancer patients. The most prevalent symptoms were changes in well-being (65.2%), anxiety (63.7%), sadness (63%) and fatigue (63%). Sadness, dyspnea, sleepiness, anxiety and depression presented weak to moderate correlation with spiritual well-being. Symptom overload showed weak negative correlation with performance.

CONCLUSIONS

symptom intensification was correlated with worsening in spiritual well-being perception. The reduction in performance was related to increased number of symptoms, especially depression and anxiety.

Consistent pressure ulcer prevention practice: The effect on PU prevalence and PU stages, and impact on PU prevention-A quasi-experimental intervention study

This study evaluates the effect of nursing staff's renewed consistent pressure ulcer (PU) prevention practice on PU prevalence and the PU prevention implemented for residents. A quasi-experimental intervention study was conducted. The data were collected from 232 residents (n = 115 in intervention and 117 in comparison group) in two public long-term older people care (LOPC) facilities in Finland using the Pressure Ulcer Patient instrument (PUP-Instrument). The facilities were chosen with convenience sampling, after which they were randomly allocated as either intervention or comparison facility. Based on international guidelines for PU prevention, the renewed, consistent PU prevention practice with six areas was developed and implemented using the operational model for evidence-based practices (OMEBP). After the intervention, a significant difference between the intervention and the comparison facility was seen in the prevalence of PUs and in the residents' highest stage of PUs in the sacrum, buttock and hip areas, and heels. Between the facilities, a significant difference was seen in the use of PU and nutrition risk assessment instruments and nutritional supplements, time used for repositioning in the daytime and at night-time, lifting belt use, and avoiding shearing or stretching residents' skin. The successful intervention improved skin integrity in LOPC facilities.

Organizational citizenship behaviour as a protective factor against the occurrence of adverse nursing-sensitive outcomes: A multilevel investigation

AIMS

This study aimed to investigate the association between organizational citizenship behaviour enacted by nurses and the occurrence of adverse nursing-sensitive patient outcomes.

BACKGROUND

Managing psychosocial factors (i.e., aspects concerning the work environment) is key to ensure patient safety, to prevent exacerbation of case complexity and to cope with critical shortages in human and financial resources.

METHODS

Self-report measures of nurses' organizational citizenship behaviour were combined with objective data on the incidence of adverse nursing-sensitive outcomes (i.e., pressure ulcers and restraint use) collected through patients' medical records. Participants were 11,345 patients and 1346 nurses across 52 teams working in 14 Italian hospitals. Data were analysed using multilevel binary logistic regression models.

RESULTS

A negative relationship between nurses' organizational citizenship behaviour and restraint use was identified, with an odds ratio of 0.11. Thus, for a one-unit higher organizational citizenship behaviour score, the odds of using restraints shrink to about one eighth of the previous level.

CONCLUSIONS

Intervention strategies to foster the implementation of organizational citizenship behaviour among nurses may inhibit the occurrence of critical outcomes affecting patients' health and well-being (i.e., using restraint devices).

IMPLICATIONS FOR NURSING MANAGEMENT

In health care organizations, shaping a psychosocial environment encouraging organizational citizenship behaviour can mitigate the occurrence of adverse nursing-sensitive outcomes such as restraint use on patients.

Overall Survival among Patients with Cancer and Pressure Injury and Its Association with Braden Scale Score

Background: The overall survival (OS) of hospitalized cancer patients with pressure injury (PI) has not been studied in a large cohort. Objective: To assess risk factors associated with OS of hospitalized cancer patients with PI. Methods: After IRB approval, charts of 445 hospitalized cancer patients with PI were reviewed. Kaplan-Meier method was used to estimate the OS time and log-rank test was used to assess the association between OS and other variables. Results: Stage 1, 2, 3, 4, deep tissue injury, unstageable, and unknown stage were 79 (17.8%), 91 (20.4%), 24 (5.4%), 3 (0.7%), 144 (32.4%), 36 (8.1%), and 68 (15.3%), respectively. The OS rate is 55.3% at one month. OS is significantly associated with Braden Scale (BS) Score. The OS time is significantly shorter in patients with advanced disease. Conclusion: Cancer patients with PI have limited OS, especially those with ≤14 BS and advanced diseases.

Is it time to re-evaluate the inevitability of ulcers at the end of life?

BACKGROUND

The prevention of pressure injuries/ulcers (PI/PUs) in patients at the end of life is achievable, albeit challenging. Objective diagnostic tools, such as sub-epidermal moisture (SEM) scanning, support healthcare practitioners' clinical judgment in preventing PI/PUs.

AIM

A pragmatic study was conducted to assess the feasibility of preventing PI/PUs using SEM technology as an adjunct to routine care in a 22-bed inpatient hospice.

METHODS

Daily SEM scanning was introduced to support the device-trained practitioners' clinical judgment in detecting developing, non-visible PI/PUs. Preventive interventions were initiated by clinical judgment informed by Waterlow scores, visible, tactile skin and tissue assessments and scanner readings.

RESULTS

Prior to the study, the incidence of PI/PUs was 9%. The 6 month study period reported a 4.8% PI/PU incidence, 7/146 consenting patients developed a PI/PU, resulting in a 47% reduction in incidence rates.

CONCLUSION

Preventing the development of PI/PUs is possible with clinical judgment aided by SEM data.

Association of overweight and obesity with the prevalence and incidence of pressure ulcers: A systematic review and meta-analysis

BACKGROUND & AIM

Pressure ulcers challenge the health status, complicate medical conditions, and affect quality of life. The aim of this systematic review and meta-analysis was to investigate the role of obesity and body weight status, as potentially modifiable risk factors, in the incidence and prevalence of pressure ulcers.

METHODS

A systematic search of observational studies was performed to assess documents published between January 1990 and December 2019 in PubMed and Scopus. Finally, 17 articles with total sample size of 2228724 in the prevalence and 218178 in the incidence study were included in the meta-analysis.

RESULTS

The pooled data analysis showed no significant effect of obesity on odds of pressure ulcers' prevalence (OR 0.91, 95% CI 0.65 to 1.27, P = 0.579, I² = 84.8%) or incidence (OR 0.97, 95% CI 0.56 to 1.66, P = 0.905, I² = 89.8%) compared with non-obese individuals. Overweight was associated with significantly lower odds of prevalence of pressure ulcers compared to non-overweight individuals (OR 0.54, 95% CI 0.33 to 0.88, P = 0.014, I² = 90.2%). The subgroup analyses showed significantly higher odds of prevalence (OR 2.38, 95% CI 1.72 to 3.29, P < 0.001, I² = 63.4%) and incidence (OR 2.28, 95% CI 1.77 to 2.94, P < 0.001, I² = 27.9%) of pressure ulcers in the underweight compared to normal weight groups. Pooled data analyses showed significantly lower odds of prevalence (OR 0.6, 95% CI 0.37 to 0.96, P = 0.034, I² = 82%) and incidence (OR 0.72, 95% CI 0.53 to 0.98, P = 0.039, I² = 67.1%) of pressure ulcers in the overweight than normal weight individuals. The findings showed no significant differences in the odds of prevalence or incidence of pressure ulcers in the obese and morbidly obese compared to normal weight individuals.

CONCLUSION

This systematic review and meta-analysis showed no significant effect of obesity or morbid obesity on the odds of pressure ulcers. Additionally, overweight was associated with lower odds of pressure ulcers while underweight significantly increased the odds of pressure injuries.

Barriers and enablers to the implementation of evidence-based practice in pressure ulcer prevention and management in an integrated community care setting: A qualitative study informed by the theoretical domains framework

Pressure ulcer reduction is a healthcare priority. Good clinical guidelines have the potential to transform pressure ulcer prevention and management practices. However, evidence suggests these guidelines are inconsistently utilised. The aim of this study was to explore health practitioners' perceived barriers and enablers to the implementation of evidence-based pressure ulcer prevention and management recommendations in an integrated community care setting. The study used a qualitative exploratory design. It took place in a community Trust in London, England. Semi-structured interviews were conducted with a purposive sample of registered nurses and allied healthcare professionals (AHPs). The Theoretical Domains Framework (TDF) informed both data collection and data analysis. Analysis followed a five-step process including deductive coding of the transcripts and inductive generation of specific belief statements. Nine nurses and four AHPs took part in the study. Six TDF domains were identified as most relevant to the implementation of best practice in pressure ulcer prevention and management: Goals, Knowledge, Skills, Beliefs about capabilities, Environmental context and resources and Social influences. All participants felt it was important to prevent pressure ulcers and were motivated to do so. Key enablers to the implementation of evidence-based practice included high levels of self-reported pressure ulcer knowledge and skills (nurses), responsive community equipment provision, the introduction of novel Pressure Ulcer Implementation Facilitator roles and integrated team working. Barriers included self-reported deficits in knowledge and skills (AHPs), worries about inspecting intimate anatomical locations (AHPs), difficulties initiating conversations with patients about risk and behaviour change, high workloads and clutter in the home. Family members and mobile working solutions were identified as both enablers and barriers. Potential routes to addressing implementation challenges are identified and recommendations made for future research.

Indicadores da Nursing Outcomes Classification para avaliação de pacientes com lesão por pressão: consenso de especialistas

Resumo Objetivos selecionar os indicadores dos resultados de enfermagem Integridade tissular: pele e mucosas (1101) e Cicatrização de feridas: segunda intenção (1103) da Nursing Outcomes Classification e construir suas definições conceituais e operacionais para a avaliação de pacientes com lesão por pressão. Métodos estudo de consenso de especialistas realizado em hospital universitário em setembro/2018. Participaram no estudo 10 enfermeiros com experiência na utilização da Nursing Outcomes Classification e no cuidado ao paciente com lesão por pressão. A coleta de dados ocorreu por meio de encontro presencial com os especialistas. Resultados Foram selecionados 17 indicadores da Nursing Outcomes Classification para a avaliação do paciente com lesão por pressão, com uma concordância de 100% entre os especialistas. São eles: Branqueamento, Eritema, Sensibilidade, Perfusão tissular, Hidratação/ Descamação, Espessura, Necrose, Odor desagradável na ferida, Pele com bolhas, Pele macerada, Descolamento Sob as bordas da Ferida, Inflamação Da Ferida, Exsudato/Drenagem, Granulação, Tunelamento, Formação de cicatriz e Tamanho da ferida. Conclusão e implicações para a prática os indicadores selecionados permitiram a elaboração de um instrumento que auxiliará na avaliação de pacientes com lesão por pressão de forma acurada. Esse instrumento subsidiará o enfermeiro na tomada de decisão diagnóstica e terapêutica da lesão por pressão.

Development and validation of the Pressure Injury Prevention Barriers questionnaire in hospital nurses in Spain

OBJECTIVE

To develop and validate a new questionnaire to measure the nurses' perceptions of the barriers towards the prevention of pressure injuries (PIs) at hospitals.

DESIGN

Validation study with mixed methods.

SETTING

Four university hospitals in southern Spain.

PARTICIPANTS

The questionnaire was developed based on a literature review. A panel of 14 wound care experts rated the content validity. A sample of 438 nurses (registered nurses and assistant nurses) participated in the survey.

MAIN OUTCOME MEASURES

The psychometric properties of the Pressure Injury Prevention Barriers (PIPB) questionnaire evaluated were: content validity, internal consistency reliability and construct validity.

RESULTS

The final version of the questionnaire has 25 items grouped into four factors (management and organisation, motivation and priority, knowledge, and staff and collaboration). The confirmatory factor analysis showed good fit and error indices for the model (Comparative Fit Index=0.92, root mean square error of approximation=0.074). Cronbach's alpha was 0.90 (overall), and 0.89 (factor 1), 0.75 (factor 2), 0.72 (factor 3) and 0.45 (factor 4). Construct validity was good, demonstrated by the expected association with the scores on patient safety culture and on considering PIs as an adverse effect of hospital stay, but not with attitude score.

CONCLUSION

The PIPB questionnaire is an instrument useful for measuring nurses' perceptions of the barriers to PIs prevention. The initial evidence shows that the questionnaire has good content validity, internal consistency and adequate construct validity. Relevance and comprehensiveness need to be assessed in further studies. It can be used both in research and in the evaluation of clinical settings to implementation of PIs preventive programmes in hospitals.

Prevalence, incidence and associated factors of pressure injuries in hospices: A multicentre prospective longitudinal study

BACKGROUND

Patients in palliative care are the population cohort that most frequently develop pressure injuries, severely impacting their quality of life. Data from prospective studies on the prevalence and incidence of pressure injuries in hospices are lacking.

AIM

To describe the point prevalence and cumulative incidence of pressure injuries in patients admitted to residential hospices, and to analyze their predictive factors over time.

DESIGN

Multicentre prospective longitudinal observational study.

SETTING/PARTICIPANTS

Adult patients (n = 992) enrolled in 13 Italian residential hospices, with a minimum sample of 280 for each macro-region (North, center, South/Islands).

METHODS

Assessments including the Karnofsky Performance Status, Braden, Edmonton Symptom Assessment System Revised scales and pressure injury staging according to National Pressure Ulcer Advisory Panel were conducted at least every four days, from admission to patients' death/discharge.

RESULTS

The 7,967 observations recorded provided prevalence and incidence rates of 34.1% and 26.5%, respectively. The logistic regression model showed non-cancer disease (OR = 2.39, 95%CI = 1.65-3.47), age >80 (OR = 2.01, 95%CI = 1.49-2.71), Braden score 'at risk' (OR = 1.92, 95%CI = 1.17-3.14), urinary catheter (OR = 1.96, 95%CI = 1.40-2.75), drowsiness (OR = 1.41, 95%CI = 1.02-1.95) and artificial nutrition (OR = 1.47, 95%CI = 1.01-2.14) as the variables associated with pressure injury at admission. The generalized estimating equations models, built on the timeframes for observation groups, revealed male gender (OR = 1.68, 95%CI = 1.01-2.79) and Braden score 'at risk' (OR = 4.45, 95%CI = 1.74-11.34) as predictive factors of a new pressure injury developed up to three weeks before a patient's death, while in the last ten days of life these predictors were replaced by diagnosis of cancer (OR = 1.80, 95%CI = 1.11-2.91), worsening pain (OR = 1.65, 95%CI = 1.10-2.49), drowsiness (OR = 1.79, 95%CI = 1.25-2.57) and dyspnea (OR = 1.48, 95%CI = 1.01-2.18).

CONCLUSIONS

The high incidence and prevalence of pressure injuries confirm the importance of palliative care nurses continuously focusing on prevention and management strategies. In the last three weeks of a patient's life, the predictive power of the Braden scale for a new pressure injury is not confirmed, throwing doubt on the effectiveness of aimed interventions at modifying risk factors. Along the different disease trajectories, pressure injuries developed during the instability/worsening phases of illness, occurring before hospice admission for non-cancer patients and in the end-of-life phase for cancer patients. Despite continuous provision of appropriate interventions, most of the new pressure injuries were detected during the last ten days of a patient's' life and assessed as 'unavoidable'. These results are crucial to guiding palliative care nursing plans during the different phases of illness, and to predicting care needs, possible management strategies ('wound management' vs. 'wound palliation'), and resource utilization.

Chitosan hydrogel encapsulated with LL-37 peptide promotes deep tissue injury healing in a mouse model

BACKGROUND

LL-37 peptide is a member of the human cathelicidin family, and has been shown to promote the healing of pressure ulcers. However, the low stability of this peptide within the wound environment limits its clinical use. Chitosan (CS) hydrogel is commonly used as a base material for wound dressing material.

METHODS

CS hydrogel (2.5% w/v) was encapsulated with LL-37. Cytotoxicity of the product was examined in cultured NIH3T3 fibroblasts. Effects on immune response was examined by measuring tumor necrosis factor-α (TNF-α) release from RAW 264.7 macrophages upon exposure to lipopolysaccharides. Antibacterial activity was assessed using Staphylococcus aureus. Potential effect on pressure ulcers was examined using a mouse model. Briefly, adult male C57BL/6 mice were subjected to skin pressure using magnets under a 12/12 h schedule for 21 days. Mice were randomized to receive naked LL-37 (20 μg), chitosan gel containing 20-μg LL-37 (LL-37/CS hydrogel) or hydrogel alone under the ulcer bed (n = 6). A group of mice receiving no intervention was also included as a control.

RESULTS

LL-37/CS hydrogel did not affect NIH3T3 cell viability. At a concentration of 1-5 μg/ml, LL-37/CS inhibited TNF-α release from macrophage. At 5 μg/ml, LL-37/CS inhibited the growth of Staphylococcus aureus. The area of the pressure ulcers was significantly lower in mice receiving LL-37/CS hydrogel in comparison to all other 3 groups on days 11 (84.24% ± 0.25%), 13 (56.22% ± 3.91%) and 15 (48.12% ± 0.28%). Histological examination on days 15 and 21 showed increased epithelial thickness and density of newly-formed capillary with naked LL-37 and more so with LL-37/CS. The expression of key macromolecules in the process of angiogenesis (i.e., hypoxia inducible factor-1α (HIF-1α) and vascular endothelial growth factor-A (VEGF-A)) in wound tissue was increased at both the mRNA and protein levels.

CONCLUSION

Chitosan hydrogel encapsulated with LL-37 is biocompatible and could promote the healing of pressure ulcers.

Barriers and facilitators for caregiver involvement in the home care of people with pressure injuries: A qualitative study

Aim

To explore the barriers and facilitators perceived by home caregivers regarding their involvement in the home care of people with pressure injuries.

Background

Although home caregivers are key in the process of caring for people with pressure injuries, little is known about their perceptions regarding their involvement in the same.

Methods

A qualitative study based on grounded theory involving a theoretical sample of 15 home caregivers of people with pressure injuries within the health district of Puertollano, Spain.

Results

This study identified three barriers (feminization of care, necessary life adaptations as a home caregiver, and the organization of health services) and three facilitators (the perceived family duty for caring, willingness to provide care, and satisfaction with the care received on behalf of primary care services) associated with caregiver involvement in the home care of pressure injuries.

Conclusions

The care of a person with pressure injuries is perceived as a duty and requires important adaptations affecting the home caregiver’s personal, social and work life. The emotional closeness and trust that develops between a patient and the primary care staff equals an involvement which, in turn, also has positive results for both the home caregiver and the patient.

Monitoring Immobilized Elderly Patients Using a Public Provider Online System for Pressure Ulcer Information and Registration (SIRUPP): Protocol for a Health Care Impact Study

BACKGROUND

Pressure ulcers represent a major challenge to patient safety in the health care context, presenting high incidence (from 7% to 14% in Spain) and increased financial costs (€400-600 million/year) in medical treatment. Moreover, they are a significant predictor of mortality. The prevention of pressure ulcers in long-term care centers and patients' own homes is proposed as a priority indicator of health care quality. Early stage risk assessment and database recording are both crucial aspects of prevention, classification, diagnosis, and treatment.

OBJECTIVE

This project proposes a 3-year study of immobilized patients residing in the Granada-Metropolitan Primary Healthcare District (DSGM) and monitored via the Pressure Ulcer Information and Registration System (SIRUPP, Spanish initials). The project aims to estimate the incidence of PUs among immobilized elderly patients, analyze the health-related quality of life of these patients by using the Pressure Ulcer Quality of Life (PU-QoL) instrument in a sample of 250 patients, determine the average time to complete wound healing, estimate the rate of pressure ulcers-associated mortality, and assess the predictive value of the Braden and Mini Nutritional Assessment risk measurement scales in a sample of 1700 patients.

METHODS

The DSGM runs SIRUPP, which is linked to patients' electronic health records. Currently, 17,104 immobilized patients are monitored under this system. Health-related quality of life will be measured by patient self-reports using the Spanish Pressure Ulcer Quality of Life questionnaire, following cross-cultural adaptation and psychometric validation with respect to the English-language version.

RESULTS

The project commenced in June 2017 and is expected to conclude in April 2020.

CONCLUSIONS

This study addresses two main health outcomes-the time needed for wound healing and the mortality associated with pressure ulcers-both of which might be accounted for by variations in clinical practice and the health-related quality of life of patients with pressure ulcers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13701.

Patients' and Caregivers' Conceptualisations of Pressure Ulcers and the Process of Decision-Making in the Context of Home Care

Background: Although the addition of patients in the process of shared decision-making can improve their recovery, there is a lack of knowledge about patients’ and caregivers’ perceptions on the management of pressure ulcers at home. Objectives: To explore the conceptualisations of patients with pressure ulcers and their caregivers on the barriers and facilitators for their involvement in home care and in the process of shared decision-making regarding the care provided. Methods: A qualitative study based on grounded theory in a theoretical sample of 10 patients with pressure ulcers and 15 main caregivers from the health district of Puertollano (Spain). The data were based on semi-structured interviews, analysed using a coding process and the constant comparative method. Results: According to the participants, personal motivation and the involvement of primary care professionals facilitated their participation in the process of shared decision-making and generated feelings of positivity. In contrast, older age, having disabling pathologies, a low educational level or health paternalism were perceived as barriers for their involvement. Conclusions: A non-paternalistic care model and personal motivation facilitate the process of shared decision-making in the care of people with pressure ulcers. Further studies are required to deepen the understanding of this phenomenon and examine the barriers and facilitators for the involvement of patients and caregivers in the management of these injuries in other contexts.

Prevalence of pressure injury among Chinese community-dwelling older people and its risk factors: A national survey based on Chinese Longitudinal Healthy Longevity Survey

AIM

To investigate the distribution of pressure injuries among older adults in China and to identify the associated risk factors.

DESIGN

Cross-sectional study.

METHODS

The identified subjects were collected from 2012 wave of a national Chinese Longitudinal Healthy Longevity Survey. Older people were defined as being 65 years of age or older. We used chi-square test and binary logistic regression to investigate the risk factors of pressure injury development.

RESULTS

A total of 55 older people were documented as suffering from pressure injuries among 6,961 older Chinese adults, with a prevalence of 0.8%. In the group of disability, the prevalence of pressure injuries from high to low was 3.6% in the highly limited group, 0.4% in the moderately limited group, and 0.3% in the not limited group. The prevalence of pressure injury among older people with stroke, cancer, and dementia were 2%, 4.2%, and 6.6%, respectively. According to the final binary logistic regression analysis, age, disability, incontinence, cancer, and dementia emerged as important risk factors for pressure injury development.

CONCLUSION

Pressure injury among Chinese community-dwelling aged people was shown to be associated with age, disability, incontinence, cancer, and dementia. As the development of pressure injury may distinctly increase the burden on individuals and healthcare systems, the social and related institutions should actively prevent and control the disease.

IMPACT

The results of this study will improve the identification of pressure injury among older Chinese people and contribute to the development of effective pressure injury risk management interventions.

Effect of health literacy of caregivers on survival rates of patients under palliative care

AIM

In this study, we aimed to investigate the effect of health literacy of the patient caregiver on the care results of palliative care patients.

METHODS

Two hundred and forty-two patients who were hospitalised in palliative care units of seven hospitals in the city in January 2018 were involved in the study. Mortality of the patients was checked 3 months later. A survey interrogating the sociodemographic characteristics of the patients and Turkish translation of Health Literacy Survey - European Union to measure the health literacy level of the caregivers were used.

RESULTS

About 19.50% of the patient caregivers are in adequate (sufficient/perfect) HL group in term of general HL. Caregivers had difficulty to access information/knowledge of what to do in case of emergency. Prevalence of bedsore occurrence in patients whose caregiver has 'inadequate' HL is higher than patients whose caregiver has 'adequate' HL. Rate of 'inadequate HL' of the caregiver is higher in dead group. As the length of hospitalisation variable value increases 1 unit, risk of mortality decreases 2%.

CONCLUSIONS

Health literacy levels of the individuals dealing with the care of palliative unit patients hospitalised in our region are low. Amelioration of health literacy of the caregivers will have a direct effect on patient health and prevention of complications. Improving health literacy must be a priority target for a more quality patient care and less complication. The issues that caregivers felt themselves insufficient should be addressed and necessary actions should be taken in the identified issues.

Opioid-Sparing Effects of Topical Ketamine in Treating Severe Pain From Decubitus Ulcers

Pain from pressure ulcers can severely impact a patient's quality of life. Evidence-based treatment of ulcer-related pain typically relies on systemic opioids with limiting side effects. Literature exists on the use of topical ketamine for neuropathic pain, but not for tissue injury in general and for decubitus ulcer pain specifically. Ketamine has a number of actions including blocking of the glutamate NMDA ionophore in the periphery. Preclinical evidence suggests that NMDA receptors located on peripheral sensory afferent terminals may play a role in initiating pain signaling in inflamed tissues. Topical ketamine, therefore, has the potential to provide analgesia when applied to decubitus ulcers. Here a case is reported of a 54-year-old female with diffuse large B-cell lymphoma who during a critical period in her illness experienced gangrene leading to chronic bilateral stage IV decubitus heel ulcers. The severe pain reported by the patient was poorly managed using high doses of systemic opioids and resulted in intermittent systemic side effects. Adding a compounded ketamine gel to her wound dressings twice daily over an interval of several months drastically reduced her opioid use and, more important, her pain, with minimal side effects.

Pressure Injury Progression and Factors Associated With Different End-Points in a Home Palliative Care Setting: A Retrospective Chart Review Study

CONTEXT

Patients with advanced illnesses show the highest prevalence for pressure injuries. In the palliative care setting, the ultimate goal is injury healing, but equally important is wound maintenance, wound palliation (wound-related pain and symptom management), and primary and secondary wound prevention.

OBJECTIVES

To describe the course of healing for pressure injuries in a home palliative care setting according to different end-points, and to explore patient and caregiver characteristics and specific care activities associated with their achievement.

METHODS

Four-year retrospective chart review of 669 patients cared for in a home palliative care service, of those 124 patients (18.5%) had at least one pressure injury with a survival rate less than or equal to six months.

RESULTS

The proportion of healed pressure injuries was 24.4%. Of the injuries not healed, 34.0% were in a maintenance phase, whereas 63.6% were in a process of deterioration. Body mass index (P = 0.0014), artificial nutrition (P = 0.002), and age <70 years (P = 0.022) emerged as predictive factors of pressure injury complete healing. Artificial nutrition, age, male caregiver (P = 0.034), and spouse (P = 0.036) were factors significantly associated with a more rapid pressure injury healing. Continuous deep sedation was a predictive factor for pressure injury deterioration and significantly associated with a more rapid worsening.

CONCLUSION

Pressure injury healing is a realistic aim in home palliative care, particularly for injuries not exceeding Stage II occurring at least two weeks before death. When assessing pressure injuries, our results highlight the need to also pay attention to artificial nutrition, continuous deep sedation, and the caregiver's role and gender.